Provider Demographics
NPI:1295791309
Name:RIVERA, NANCY DENNISSE (MD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:DENNISSE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:DENNISSE
Other - Last Name:RIVERA-KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20 MAYO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1442
Mailing Address - Country:US
Mailing Address - Phone:410-956-6800
Mailing Address - Fax:410-956-6803
Practice Address - Street 1:1209A MARDA LN
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-1706
Practice Address - Country:US
Practice Address - Phone:410-353-9323
Practice Address - Fax:410-877-6807
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD300P610GMedicare PIN
D98096Medicare UPIN
MD394076Medicare PIN
MD296561YE59Medicare PIN
D98096Medicare UPIN